Financial decision analysis based on "willingness to pay" for surgical sperm retrieval approaches among men with non-obstructive azoospermia in the United States.

OBJECTIVE: To determine the most financially optimal surgical approach for testicular sperm retrieval for men with non-obstructive azoospermia (NOA).

DESIGN: A decision tree was created examining five potential surgical approaches for men with NOA pursuing one cycle of ICSI. An expected financial net loss was determined for each surgical option based on couples' willingness to pay (WTP) for one cycle of ICSI resulting in pregnancy. The branch with the lowest expected net loss was defined as the most optimal financial decision (minimizing loss to a couple). Fresh TESE implied TESE was performed in conjunction with programmed ovulation induction. Frozen TESE implied TESE was performed initially, and ovulation induction/ICSI was canceled if sperm retrieval failed.  The surgical options included fresh conventional TESE (c-TESE, with and without "back-up" sperm cryopreservation), fresh microsurgical TESE (m-TESE, with and without "back-up" sperm cryopreservation), and frozen m-TESE. Success was defined as pregnancy after one ICSI cycle.

MATERIALS AND METHODS: Probabilities of successful sperm retrieval with c-TESE/m-TESE, post-thaw sperm cellular loss following frozen m-TESE, ovulation induction/ICSI cycle out-of-pocket (OOP) costs, ICSI pregnancy rates for men with NOA, standard c-TESE cost and average WTP for ICSI cycle were gathered from systematic literature review. Costs were in USD and adjusted to inflation (as of April 2020). Two-way sensitivity analysis was performed on varying couples' WTP for one cycle of ICSI and varying m-TESE OOP costs.

RESULTS: According to our decision tree analysis (assuming minimum m-TESE cost of $1,000 and WTP of $8,000), the expected net loss for each branch was as follows: -$17,545 for fresh c-TESE, -$17,523 for fresh m-TESE, -$9,624 for frozen m-TESE, -$17,991 for fresh c-TESE with backup, and -$18,210 for fresh m-TESE with "backup". Two-way sensitivity analysis with variable WTP values and m-TESE and IVF costs confirmed that frozen m-TESE consistently presented the lowest net loss compared to other options. Interestingly, when directly comparing fresh m- and c-TESE with "back-up", scenarios with decreasing WTP and lower m-TESE costs demonstrated fresh c-TESE with "back-up" as more optimal than fresh m-TESE with "back-up".

CONCLUSIONS: For those couples who must pay out of pocket, our study suggests that frozen m-TESE is the most financially optimal decision for the surgical management of NOA, regardless of m-TESE cost and couple's WTP. This article is protected by copyright. All rights reserved.